|Year : 2014 | Volume
| Issue : 4 | Page : 283-286
Idiopathic multiple unerupted permanent teeth: A rare case report
Sandra Vani1, Anitha Nooney1, Kakarla Subba Raju1, Melpati Hemadri2
1 Department of Orthodontics and Dentofacial Orthopedics, C. K. S. Teja Institute of Dental Sciences and Research, Tirupati, Andhra Pradesh, India
2 Department of Conservative Dentistry, C. K. S. Teja Institute of Dental Sciences and Research, Tirupati, Andhra Pradesh, India
|Date of Web Publication||10-Dec-2014|
Department of Orthodontics and Dentofacial Orthopedics, C. K. S. Teja Institutions of Dental Sciences, Tirupati - 517 501, Andhra Pradesh
Source of Support: None, Conflict of Interest: None
A disturbed eruption process creates a clinical situation that is challenging to diagnose and treat. The clinical spectrum of tooth eruption disorders includes both syndromic and nonsyndromic problems ranging from delayed eruption to a complete failure of eruption. Failure of permanent teeth to erupt without obvious etiology is a rare dental anomaly. Various local and systemic factors have been implicated in failure of eruption of multiple permanent teeth. The present case report discusses the clinical and radiographic details of a 21-year-old asymptomatic and nonsyndromic patient with multiple unerupted permanent teeth.
Keywords: Idiopathic, permanent dentition, primary teeth, unerupted teeth
|How to cite this article:|
Vani S, Nooney A, Raju KS, Hemadri M. Idiopathic multiple unerupted permanent teeth: A rare case report. J NTR Univ Health Sci 2014;3:283-6
| Introduction|| |
Tooth eruption has been defined as the movement of a tooth in an axial and occlusal direction from its developmental position within the jaw to its final functional position in the occlusal plane.  The eruption pattern of deciduous and permanent teeth is usually comprehensive and takes place at different chronological age levels. A significant deviation in eruption of tooth, premature eruption and delayed tooth eruption are commonly noted in a clinical practice.  Possible etiologies for failure of eruption of teeth fall into two broad categories: systemic and local factors. Some of the systemic conditions that can lead to delayed or failed eruption are genetic disorders such as cleidocranial dysplasia, Gardner syndrome and osteopetrosis. , Endocrine derangements like hypothyroidism can also cause generalized underdevelopment and delayed eruption of the dentition. , In general, systemic causes lead to widespread impact on most of the dentition, as opposed to local factors that tend to affect a smaller number of teeth.
Local causes are varied and range from physical barriers to local metabolic disturbances, trauma and infection. , Probably, the most common local factor is mechanical obstruction either integral or peripheral to the tooth. Barriers can also be of soft tissue origin, as in tumors and cysts.  Nonsyndromic multiple eruption disorders are rarely reported. ,,,,,
Apparently, this indicates that most of the multiple unerupted teeth are often associated with different local, systemic, and genetic factors. This case report describes a patient with multiple unerupted permanent and deciduous teeth for which there is no obvious explanation. He has no associated systemic illness, no underlying endocrine dysfunction and no associated genetic abnormality.
| Case report|| |
A 21-year-old male patient in good general health came with the chief complaint of multiple missing teeth in upper and lower jaws and wanted to have prosthesis made for the same. His past medical history was completely unremarkable. Born to nonconsanguineous parents, he was the product of full-term pregnancy and an uncomplicated delivery with no history of radiation or unusual drug therapy during gestation. No one in the family had unerupted teeth or missing teeth.
On general examination, patient was moderately built and nourished and did not exhibit any physical or skeletal abnormality and showed no signs of mental retardation. To rule out any associated syndromes, metabolic and hormonal disorders, patient was referred to a physician under whose supervision, multiple tests, including karyotyping, thyroid function tests, parathormone levels, hormone assays, serum calcium, and phosphorous levels were carried out. The results of the investigations were within normal limits.
Intra-oral examination [Figure 1] revealed multiple retained deciduous teeth with respect to 55, 54, 53, 63, 65, 73, 74, 83 and 84, with only permanent maxillary and mandibular central incisors present. Root stump of maxillary left first primary molar was retained. The anatomy of erupted teeth was normal. A complete anterior deep bite was present. No oral mucosal lesions were found. On palpation, there is bulging in relation to unerupted teeth with no signs of pain or crackling.
Panoramic radiograph [Figure 2] revealed 9 retained deciduous teeth, 13 unerupted permanent teeth in the maxilla and 16 unerupted teeth (2 deciduous, 14 permanent) in the mandible. In total, the patient has 29 unerupted teeth: 13, 14, 15, 16, 17, 18, 22, 23, 24, 25, 26, 27, 28, 75, 85, 32, 33, 34, 35, 36, 37, 38, 42, 43, 44, 45, 46, 47, and 48. Permanent maxillary right lateral incisor was congenitally missing. Impacted teeth were crowded in maxillary and mandibular anterior region. In the mandibular arch, they were very close to the inferior border of mandible. Root development was complete for all unerupted permanent teeth except third molars. Unerupted deciduous teeth in mandible showed no evidence of root formation. Roots of maxillary second molars, mandibular lateral incisors, canines, first premolars, first and second molars were aberrantly angulated. Jaw bones showed normal trabecular pattern and density.
|Figure 2: Panoramic radiograph showing unerupted and|
malpositioned permanent teeth with complete development of
roots and presence of many deciduous teeth with incomplete root
Click here to view
| Discussion|| |
The case described, represents unique characteristics of multiple unerupted permanent teeth, multiple retained deciduous teeth, unerupted mandibular primary second molars, and congenitally missing lateral incisor in an asyndromic male patient.
Multiple unerupted permanent teeth is a rare finding and frequently found to be associated with syndromes such as cleidocranial dysplasia, Gardner syndrome, Zimmerman-Laband syndrome and Noonan's syndrome. ,,, Primary teeth are retained in conditions like hemifacial atrophy, hypopitutarism, hypothyroidism, cherubism, gingival fibromatosis, and cleft palate.  On account of the fact that family history, medical history, clinical examination, biochemical and hematological reports were non-contributory in our patient, all the above conditions were excluded. Intra-oral examination of the patient revealed relatively normal jaws and oral soft tissues excluding involvement of local etiological factors such as the presence of mucosal barrier, supernumerary teeth, tumors, and scar tissue.
Many nonsyndromic cases of multiple unerupted teeth reported were supernumerary or a combination of supernumerary and permanent teeth. ,, Our patient had no supernumerary teeth. Only three cases of similar nature but varying severity have been reported.
O'Connell and Torske  described a case with full retarded eruption of both deciduous and permanent dentition. Bayar et al.  have reported three cases with multiple impacted teeth involving both jaws in which no syndrome or systemic conditions have been detected. Dalampiras et al.  described a case of 13-year-old boy with retained primary teeth and retarded eruption complete permanent dentition.
Impaction of succedaneous teeth due to over retention of primary teeth has been reported widely in the literature. ,, Involvement of both succedaneous and nonsuccedaneous teeth in our patient establishes the fact that failure of eruption of teeth or lack of eruptive forces led to retention of primary teeth. The presence of over retained primary teeth as seen in this patient is considered a consequence rather than a cause for failure of eruption. Since there is no eruptive mechanism most of the primary teeth roots are not resorbed and retained. This may be one of the predictable causes for delayed exfoliation of primary teeth.
Mandibular deciduous second molars on both sides failed to erupt in our patient. Yildirim et al.  have reported a case of multiple impacted permanent teeth along with five impacted primary teeth. Impactions and tooth eruption failures involving the primary teeth are rare. Second primary molars have been the teeth most frequently involved. Impaction of primary teeth may be associated with the eruptive and developmental disturbances in their permanent successors. , During the embryological developmental course as it occurs in the premolar region, permanent tooth bud changes its position from the region around the occlusal surface of the primary molar to an interradicular position on the primary molar. In the present case mandibular second premolars are located occlusal to the primary second molars as in the cases reported by Memarpour et al. and Borsatto et al. , It may be assumed that abnormal position of premolars is due to early arrest in the eruption of the primary primordium preventing the migration of permanent tooth germ to an interradicular position below the non-erupting primary molar as under normal condition. Instead it will erupt independently and obtain a position occlusal to the primary molar. 
Most of the teeth involved had completed root development, a fact which confirms that root formation is independent of the eruption process. Root dilacerations were seen not only in mandibular first and second molars, but also in mandibular lateral incisors, canines and first premolars and maxillary second molars too. Vedtofte et al.  reported an association between root anomalies and eruptive disorders in permanent molars, but the finding has not been quantified. Kaban et al. states that the follicle of unerupted molars near the inferior border begins to curve, resulting in "hooked" roots. Root deflection may be due to the local disturbance leading to failure of eruption and presence of dilacerated roots determines a poor prognosis. In this case, failure of posterior dentoalveolar development resulted in excessive anterior overbite.
In our patient, lack of eruptive force from the dental follicle combined with idiopathic displacement of secondary tooth germs resulted in many unerupted permanent teeth.
| Conclusion|| |
Failure of permanent teeth to erupt can be attributed to genetic, systemic and local causes. Retained deciduous teeth with multiple unerupted permanent teeth in this case were not associated with systemic or local etiology. Hence, diagnosis of idiopathic failure of eruption was made. Interdisciplinary management is essential in such cases for optimal outcome to restore function and esthetics. Orthodontic-assisted eruption will not be possible in this case due to lack of sufficient number of permanent teeth for conventional anchorage and ideal location for placement of microimplants. Aberrantly impacted teeth with divergent roots require extensive bone removal contraindicating surgical extractions. Therefore, placement of overdentures subsequent to endodontic treatment was planned.
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[Figure 1], [Figure 2]